改良式阴茎静脉截除手术

手术原理

勃起功能障碍（ED）的关键致病因素之一是阴茎静脉血管渗漏。当勃起开始时，动脉血管扩张、阴茎海绵体内平滑肌松弛，大量血液经由阴茎动脉灌注进入海绵体内造成充血膨胀。若此时阴茎静脉系统未能有效闭合而发生静脉漏，血液将快速流出海绵体，导致勃起困难、硬度不足或过快疲软等勃起功能障碍。阴茎静脉渗漏程度因人而异，勃起硬度也会表现出不同差异。为了达到满意的勃起效果，改良式阴茎静脉截除手术的目的在于阻滞阴茎静脉血液回流，增加勃起期间海绵体内的储血量，维持充分且有效的勃起硬度。

麻醉方式

施行阴茎静脉手术，传统上通常采用椎管内半身麻醉或全身麻醉。

本院采用创新的双重局部麻醉技术，包括阴茎背神经近端阻滞术与阴茎根部浸润阻滞术，仅在阴茎根部注射局麻药物（图1）。手术全程清醒无痛，患者可使用手机或佩戴蓝牙耳机轻松听音乐。

手术切口

位于下耻骨部的单一微创切口，长约3厘米。

若同时施行包皮环切手术，冠状沟下方将另有一环形切口。

是否需要住院

无需住院或留院观察。属于门诊日间手术，术后即可自行步行离院返家休息。

手术方法与步骤

患者取平卧位，在精准的双重局部麻醉下施行手术。以最新发现的详尽阴茎静脉系统解剖构造作为手术导引（图2）。

应用显微外科技术，于下耻骨部正中做长约3厘米纵行切口；若合并包皮环切则配合相应切口。精细分离切口内组织（图3-1），将阴茎本体外翻脱套（图3-2）。贴近白膜使用微细缝线细致结扎并完整截除正中的深背静脉及两侧海绵体静脉（图3-3），对动脉旁静脉、环状静脉与脚静脉等细小分支亦予以妥善缝扎，阻滞静脉血液外漏回流。随后将阴茎本体复位，以极细缝线缝合切口，并立即使用无菌纱布加压包扎（图3-4）。术中完整保留浅背静脉和球尿道静脉以维持正常生理循环。整项手术出血极微，完全不使用电灼止血，所有出血点均以显微缝线结扎止血，避免高热对毗邻神经与动脉造成热损伤，显著降低并发症风险。

本院手术特色

• 新式双重局部麻醉，安全性高：免除全身或半身麻醉（包括静脉镇静）风险；麻醉镇痛维持时间长，术后伤口痛感显著减轻。
• 单一微创切口（约3厘米）：位置隐蔽，愈合迅速。
• 无需住院：日间门诊手术，术后即可自由步行回家。
• 前沿解剖学指引：彻底阻断病理性回流静脉，截除精细完整。
• 不需电灼止血，杜绝热损伤：电灼会造成局部组织炭化缺血并可能伤及神经；本院坚持显微缝扎止血，充分保护勃起神经与血管完整。
• 精细显微外科技术：高倍视野下精准操作，提高手术安全性，尽量降低并发症风险。

手术预后与成效

传统阴茎静脉手术早期短期改善率约为50%至80%，但长期随访改善率常回落至31%至64%，主要与静脉结扎不彻底、海绵体平滑肌功能障碍及个体衰老相关。

在严格评估并筛选合适病例的前提下，采用改良式阴茎静脉截除手术，长期随访证实90.4%的患者勃起功能获得显著改善，国际勃起功能指数（IIEF）统计学上有显著提高，另一临床研究显示满意度达87.9%。与传统手术相比，显微改良式手术严重并发症极少，仅偶见短暂性水肿或皮下淤青，长期随访未见严重不良反应。

结语

阴茎静脉渗漏是导致勃起功能障碍的重要且常被忽视的关键诱因。在充分掌握阴茎血管微细解剖的前提下，改良式阴茎静脉截除手术能带来显著优于传统手术的临床效果，在长期文献报告中均获得高度肯定。

对于经过专业评估适合手术的静脉漏患者，改良式阴茎静脉截除手术是治疗勃起功能障碍切实可行的重要方案，帮助患者恢复自然、自发且无需依赖药物的勃起能力。将显微血管手术与心理疏导、PDE5抑制剂、低能量体外冲击波及内分泌调理等多靶点治疗有机结合，可获得更佳的综合疗效；在终末期严重器质性病变患者中，人工阴茎假体植入亦为最终保障。

期刊论文

1. Hsu GL(許耕榕), Hsieh CH(謝政興), Chen HS, Ling PY, Wen HS, Liu LJ, Chen CW, Chua C. The advancement of pure local anesthesia for penile surgeries: can an outpatient basis be sustainable (純粹局部麻醉施行陰莖手術的新進展). Journal of Andrology. 28(1):200-205, 2007.
2. Hsu GL, Zaid UX, Hsieh CH (謝政興), Huang SJ. Acupuncture assisted local anesthesia for penile surgeries (針灸輔助局部麻醉下施行陰莖手術). Translational Andrology and Urology. 2(4):291-300, 2013.
3. Hsu GL(許耕榕), Hsieh CH(謝政興), Wen HS, Hsu WL, Chen YC, Chen RM, Chen SC, Hsieh JT. The effect of electrocoagulation on the sinusoids in the human penis (電燒止血對於人類陰莖海綿體的影響). Journal of Andrology. 25(6):954-959, 2004.
4. Hsu GL(許耕榕), Hsieh CH(謝政興), Wen HS, Chiang HS. Penile venous anatomy: application to surgery for erectile disturbance (陰莖靜脈解剖構造：在勃起功能障礙手術中的應用). Asian Journal of Andrology. 4(1):61-66, 2002.
5. Hsu GL(許耕榕), Hsieh CH(謝政興), Wen HS, Chen YC, Chen SC, Mok MS. Penile venous anatomy: an additional description and its clinical implication (陰莖靜脈解剖構造：附加描述及其臨床意涵). J Androl. 2003; 24: 921-927.
6. Hsu GL(許耕榕), Hsieh CH(謝政興), Wen HS, Hsu WL, Wu CH, Fong TH, Chen SC, Tseng GF. Anatomy of the human penis: the relationship of the architecture between skeletal and smooth muscles (人類陰莖解剖構造：骨骼肌和平滑肌之間的結構關係). Journal of Andrology. 25:426-431, 2004.
7. Hsieh CH(謝政興), Wang CJ, Hsu GL(許耕榕), Chen SC, Ling PY, Wang T, Fong TH, Tseng GF. Penile veins play a pivotal role in erection: the hemodynamic evidence (陰莖靜脈在勃起中扮演關鍵角色：血液動力學上的證據). International Journal of Andrology. 28(2):88-92, 2005.
8. Chen SC, Hsieh CH(謝政興), Hsu GL(許耕榕), Wang CJ, Wen HS, Ling PY, Huang HM, Tseng GF. The progression of the penile vein: could it be recurrent (陰莖靜脈的進展：陰莖靜脈手術後是否會復發)? Journal of Andrology. 26(1):53-60, 2005.
9. Wen HS, Hsieh CH(謝政興), Hsu GL(許耕榕), Kao YC, Ling PY, Huang HM, Wang CJ, Einhorn EF. The synergism of penile venous surgery and oral sildenafil in treating patients with erectile dysfunction (陰莖靜脈截除手術與口服威而剛治療勃起功能障礙的協同作用). International Journal of Andrology. 28(5):297-303, 2005.
10. Hsu GL(許耕榕), Chen HS, Hsieh CH(謝政興), Lin PL, Wen HS, Liu LJ, Chen CW, Liu MW. Insufficient response to venous stripping surgery: is the penile vein recurrent or residual (陰莖靜脈截除手術後反應不佳：陰莖靜脈復發或殘留?). Journal of Andrology. 27(5):700-706, 2006.
11. Hsu GL(許耕榕), Chen HS, Hsieh CH(謝政興), Lee WY, Chen KL and Chang CH. Salvaging penile venous stripping surgery (陰莖靜脈截除挽救手術). Journal of Andrology. 31(3):250-260, 2010.
12. Hsu GL(許耕榕), Chen HS, Hsieh CH(謝政興), Lee WY, Chen KL and Chang CH. Clinical experience of a refined penile venous stripping surgery procedure for patients with erectile dysfunction: is it a viable option (精煉的改良式陰莖靜脈截除手術治療勃起功能障礙的臨床經驗：手術是可行的選擇?). Journal of Andrology. 31(3):271-280, 2010.
13. Hsu GL(許耕榕), Hung YP, Tsai MH, Hsieh CH(謝政興), Chen HS, Molodysky E, Huynh CC, Yu HJ. Penile veins are the principal component in erectile rigidity: a study of penile venous stripping on defrosted human cadaver (陰莖靜脈是達成勃起硬度的主要因素：在解凍的人類屍體上進行陰莖靜脈截除手術的研究). Journal of Andrology. 33:1176-1185, 2012.
14. Hsieh CH(謝政興), Hsieh JT, Chang SJ, Chiang IN, Yang SSD. Penile venous surgery for treating erectile dysfunction: past, present, and future perspectives with regard to new insights in venous anatomy (陰莖靜脈手術治療勃起功能障礙的過去、現在與未來：陰莖靜脈解剖學的新見解). Urological Science. 27(2):60-65, 2016.
15. Hsieh CH(謝政興), Hsu GL(許耕榕), Chang SJ, Yang SSD, Liu SP, Hsieh JT. Surgical niche for the treatment of erectile dysfunction (手術治療勃起功能障礙的利基). International Journal of Urology. 2020; 27: 117-133.

书籍著作

1. Cheng-Hsing Hsieh (謝政興), Geng-Long Hsu. Current role of vascular surgery (arterial and venous) in erectile dysfunction (當前動脈及靜脈血管手術在勃起功能障礙中的角色), in INTERNATIONAL BOOK OF ERECTILE DYSFUNCTION, M.L. Djordjevic and F.E. Martins, Editors. 2016, Nova Science Publishers, Inc.: New York. chap. 9, pp. 129-157. ISBN: 978-1-63485-289-0
2. Geng-Long Hsu, Cheng-Hsing Hsieh (謝政興), Eric Allaire. Vascular (Arterial and Venous) Surgery for Erectile Dysfunction (血管(動脈與靜脈)手術治療勃起功能障礙), in Textbook of Male Genitourethral Reconstruction, Francisco E. Martins, Sanjay B. Kulkarni and Tobias S. Köhler, Editors. 2020, Springer Nature: Switzerland AG. chap. 50, pp. 663-678. ISBN: 978-3030214463  
3. Cheng-Hsing Hsieh (謝政興)、Geng-Long Hsu (許耕榕). 治療勃起功能障礙 – 手術治療(Erectile Dysfunction – Surgical Management).書名：男性性功能障礙 – 臨床診治全攻略 (Male Sexual Dysfunction – A Complete Guide to Diagnosis and Treatment), 陳煜、簡邦平、蔡維恭、陳卷書編輯. 合記圖書出版社, 2023. 第三篇，第17章，頁245-262.  
4. Cheng-Hsing Hsieh (謝政興)、Geng-Long Hsu (許耕榕). 勃起功能障礙 – 手術治療 (Erectile Dysfunction – Surgical Treatment). 書名：臨床泌尿學 (CLINICAL UROLOGY).郭漢崇、賴明坤、楊啟瑞、黃一勝、余燦榮、陳進典、崔克宏,編輯. 台灣泌尿科醫學會, 2012.第八篇，第54章，頁1037-1049. 
5.  Geng-Long Hsu (許耕榕)、Cheng-Hsing Hsieh (謝政興). 書名：A LABORATORY MANUAL FOR POTENCY MICROSURGERY (性功能顯微手術實驗訓練手冊). 許耕榕、謝政興,編輯.

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